Experimental and clinical investigations on the transfusion of autologous blood in urological operations

In view of the known risks in homologous blood transfusions, the procedures for transfusion of endogenous blood are gaining increasing importance. Using this fact as a basis, the feasibility of direct intraoperative autotransfusion in the area of urology was investigated. 6 mongrel dogs received blood-urine autotransfusions after cystotomy and cavotomy (n = 2) as well as after left-side nephrotomy (n = 4). Coagulation and hemolysis parameters were examined 1, 2, 24 h and 7 days after the autotransfusion, and showed transitory pathological changes which were, without exception, reversible within 7 days. Clinical effects were not observed. On the basis of favorable experience, the intraoperative, machine autotransfusion was also used clinically for renal traumas (n = 13), urinary bladder traumas (n = 4) and nephrotomies (n = 3). Postoperative checks showed pathological changes in the hemolysis and coagulation values only during the first 3 postoperative days. The blood-urine autotransfusion was well tolerated without exception. Indications and contraindications for direct intraoperative autotransfusions in the area of urological operations are discussed.

Autotransfusion: current status

Autotransfusion is the collection of blood from a patient and the reinfusion of that same blood back to that patient. Historically, it has been used since 1818, and there have been many rebirths of this technique since its beginning. Many problems encountered have caused the technique to be abandoned; but as devices become refined, interest is restimulated. There are many advantages to autotransfusion including the preservation of an extremely important natural resource, blood. Expanding massive surgical procedures are increasing demands on blood supplies, and autotransfusion is a safe, logical way to decrease demands and save blood. Devices presently available are discussed and described.

[Intraoperative autotransfusion, technical management and its influence on blood circulation, on kidney and electrolytes (author's transl)]

From February 1975 until July 1976 12 patients who elective surgery and 15 trauma victims received intraoperative autotransfusion. The effects of this method on these patients were controlled by monitoring the behaviour of circulation and of important laboratory parameters. The procedure was well tolerated: 1. Only three of 29 patients showed evidence of cardiac insufficiency (lowering of ST. elevated T-peak, low blood pressure, high central venous pressure) which disappeared after reducing the rate of infusion. --2. Blood pressure, pulse rate and central venous pressure were stable at the end of the operation. --3. There was no renal insufficiency under dopamine (210 microgram/min) and 15% manitol (250 ml i.v.). --4. Serum creatine showed only minor changes from the initial level during the time of observation. --5. The same was true for beta2-microglobulin. --6. Serum urea rose slightly during 7 days. --7. There were minor changes of electrolytes without hypocalcaemia or high potassium. --8. The observed changes showed no relation to the method of anticoagulation and to time or volume of autotransfusion.

[Intraoperative autotransfusion and haemolysis (author's transl)]

In 29 patients (12 vascular and 17 trauma cases) receiving autotransfusion the effects of haemolysis caused by the Bentley ATS-system were examined. The following parameters were monitored: 1. Overall haemolysis rate and fractions in serum and urine, --2. Total and direct bilirubin in all patients with or without preexisting icterus, --3. Plasma-proteins: Albumen, haptoglobin, haemopexin, transferrin and C3-activator. --In both groups extremely high rates of free haemoglobin in serum were found in some cases. The peak of haemoglobinuria was observed several hours after the autotransfusion or at the end of the operation. The different plasma proteins showed increased activity to cope with haemolysis within the first 24 h. After one week they still showed overshooting levels in some cases which permitted conclusions concerning the extent of the reactions. The transformation of free haemoglobin in bilirubin has to be strongly suspected. The changes of the parameters were not in relation to the volume of autotransfusion. No irreversible complications due to haemolysis caused by the autotransfusion systems were observed.

An autotransfusion apparatus

An autotransfusion apparatus is described in detail and its use is illustrated with short case reports.

[Intraoperative autotransfusion and its influence on the blood-clotting-system (author's transl)]

In 12 vascular and 17 trauma cases the changes in the coagulation system due to intraoperative autotransfusion (IAT) were examined immediately after the IAT as well as 24, 48, 72 h and one week later. The following parameters were monitored: 1. Platelet count. --2. Prothrombin-time, partial-thromboplastin-time, factors II, V, VII, X and thrombin-clotting-time. --3. Fibrinogen, alpha-1-antitrypsin, alpha-2-macroglobulin, antithrombin III and plasminogen in 5 trauma cases. --4. Euglobulin-Lysis-Time. --After the IAT a loss of platelets, factors I, II, V, X, plasminogen and antithrombin III was found. Alpha-1-antitrypsin and alpha-2-macroglobulin remained unchanged or showed a slight increase. 24 h after treatment with Ugurol and heparin, fresh frozen plasma, fibrinogen and Cohn I-fraction in selected cases, an increasing normalisation of most parameters was seen, except for the plasma proteins active in coagulation. They showed a combination of "consumption coagulophathy" and "hyperfibrinolysis" up to the 7th day. Under treatment outlines above even marked laboratory changes remained without any clinical significance. Thus our results confirm that IAT does not cause any additional irreversible damage to the coagulation system. Therefore IAT can be considered as method of choice for the emergency treatment of massive bleeding.

Cardio-respiratory synchronisms: synchrony with artificial circulation

Rabbits with an artificial cerebral circulation can synchronize their respiratory rhythm with the pump stroke. There is evidence that the responsible kybernetic system is of a very elementary nature. The efficacy of the system is considerable and the experimental set-up as a whole offers itself as a model to search for drugs to increase the synchronizing potentialities.

A practical method of autotransfusion in the emergency center

A new mobile autotransfusion device, modified for use in the Emergency Center, is described. Preliminary usage in thirty trauma patients who underwent autotransfusion of 60 units of blood indicated the device was simple to utilize, efficacious, inexpensive, cost-effective, and safe.

[Intraoperative instrumental autotransfusion. 1st experiences in vascular surgery and traumatology]

Intraoperative autotransfusion with the Bentley-ATS system was performed in 22 patients, saving a total of 98 000 ml of their own blood. In addition 77 000 ml of homologous blood were given, intraoperatively. Eleven patients underwent major vascular surgery and 11 were operated for major traumatic injuries. There was a total of 11 deaths overall but none related to the autotransfusion. It is concluded that intraoperative autotransfusion is a safe and simple method of rapid transfusion which can save significant volumes of precious homologous blood.

Laboratory experience with a new autotransfusion device

A new device for collecting and administering blood by intraoperative autotransfusion consists of several novel features: a collection bag that is kept expanded by a vacuum and into which the blood is drawn by suction of a lesser degree than the outside vacuum, a crease in the collection bag that decreases turbulence and foaming, and separation of the infusion element from the retrieval system by a valve that allows pressure infusion and suction continously. The apparatus is inexpensive, quickly assembled, operated by wall suction or suction pump. We have had favorable experience with its use in animals.

Intraoperative autotransfusion: an underutilized technique

Although interest in intraoperative autotransfusion increased when commercial equipment became available, this technique still is utilized rarely in most hospitals. Our experience began with sporadic use in 1972 and has evolved to regular use at least ten times a month. The machine is operated by a technician, and we heparinize the autotransfusion system (ATS) reservoir. Our series includes 47 patients who had elective vascular operations and 141 who had emergency operations, usually for trauma. In the latter group, seven patients who were autotransfused with blood contaminated by intestinal contents survived near fatal injuries and did not develop complications attributable to the procedure. Morbidity and mortality rates in both groups did not appear to be increased as a result of intraoperative autotransfusion. Controversy over methods of anticoagulation and apprehension about effect on blood are not valid reasons for underutilization of this technique. Although significant administrative commitments are required to implement its use and to treat the coagulopathy that accompanies massive reinfusions, they are justified by the value of intraoperative autotransfusion in most cases in which two or more units of blood would be required ordinarily.

Intraoperative autotransfusion: equipment, protocols, and guidelines

Blood obtained by intraoperative autotransfusion is: 1) readily available 2) sterile 3) compatible 4) normothermic 5) inexpensive and may be infused rapidly for volume support. We have made extensive modifications to commercially available equipment in order to provide a safe, effective IAT. The effects of IAT in our series of 85 patients are outlined below. Red Cell Mass is reduced after IAT because of irretrievable blood loss and hemolysis, and may be controlled by homologous transfusion when necessary. Red Cell Survival is normal after IAT. Hemolysis. Plasma free hemoglobin is consistently elevated after IAT, but clears within 24 hours. Platelets are normal for patients autotransfused less than 3,500 ml; micropore filters should not be used in cases where greater than 3,500 ml blood is expected to be reinfused; in cases where greater than 3,500 ml is reinfused, 10 units of platelets are recommended for every 3,000 ml of blood reinfused; IAT does effect platelets function; however, platelets circulating within the patient function normally. Coagulation. We use local ACD to eliminate extracorporeal surface clotting. Even with massive IAT we have never demonstrated any clinical or laboratory evidence of intravascular coagulopathy. "Dilutional coagulopathy" may be procuced when greater than 5,000 ml are reinfused, and may be controlled with fresh frozen plasma and platelet concentrates. Bilirubin levels were normal after IAT despite gross hemoglobinuria. Fat emboli were not noted after IAT. Air emboli must be a concern in IAT; HOWEVER, PROPER OPERATION AND EQUIPMENT MODIFICATION MAY ELIMINATE EMBOLI. Renal Failure was not noted after IAT. Alveolar-arterial Oxygen Difference and Blood Gases were normal after IAT. We feel IAT is not necessary if a blood loss less than 1,000 ml is expected. Also, if greater than 3,500 ml is expected additional backup (i.e. homologous transfusions, platelets, fresh frozen plasma) may be required. As banked donor blood reserves become more limited, IAT may become a routine part of general surgical procedures.

[Intraoperative autotransfusion in gynecology and surgery (author's transl)]

The technique of intraoperative autotransfusion (AT) is being used to date only in a few individual clinics. Since there is a clinically safe and economical AT-apparatus available the routine application of this rational blood replacement method is easy to perform. The authors have used this technique altogether in 111 patients, applying the Bentley-ATS-machine in the last 69 cases. In a previous series of 42 cases AT was used for ruptured ectopic pregnancy, in the series of 69 surgical cases for hemothorax or intraabdominal hemorrhages of mainly traumatic origin. The most frequent indications for AT in emergency surgical operations were ruptures of spleen and liver, and in elective surgery for portocaval shunt. Altogether 247 litres of blood have been retransfused with an AT-volume per patient ranging from 0,5 to 15 litres. For anticoagulation generally ACD was used, only in vascular surgery was heparin preferred. Methodical complications have not been seen. Technique, indications, consequences and possible complications of AT are described. The main advantages of autologous intraoperative transfusion are the immediate availability of blood, the absence of the risk of hepatitis and of incompatibility reactions, reduction of pressure on the blood banks and lower transfusion costs. The authors therefore believe that the possibility of intraoperative AT should exist at every surgical and gynecological clinic.

Ultrastructural damage of leukocytes procured by the Leukopak: vulnerability of leukocytes to mechanical injury

Because of the often observed undesired effects in patients transfused with leukocytes collected by continuous filtration leukapheresis (CFL), we have investigated the morphology of these cells in the hope that such studies may help evaluate their in vivo functions. Aliquots of CFL samples, procured by the Fenwal Leukopak and taken before and after tapping the filters, were examined. Leukocytes prepared by dextran sedimentation served as controls and were used to demonstrate the vulnerability of these cells to mechanical injury. The morphology of leukocytes harvested by filtration leukapheresis was markedly altered, ranging from formation of cytoplasmic projections and vacuoles to disintegration of entire cells. The severe changes were only observed in samples collected after the filters were tapped. The number of cells involved varied from donor to donor. In some cases more than half of the examined leukocytes showed signs of damage. Dextran sedimentation leukocytes retained their normal ultrastructure. However, substantial injuries were inflicted on dextran sedimentation collected leukocytes following brief periods of vortexing. Our results indicate that leukocytes are quite vulnerable to mechanical injury, and the major cause of damage found in Leukopak-isolated leukocytes is the tapping of the filters. The toxic reactions in some recipients transfused with Leukopak-collected leukocyte preparations may result from materials released from disrupted leukocytes. We believe that the employment of the continuous filtration to procure leukocytes with the present procedure should be reviewed.

Intraoperative autotransfusion in major elective vascular operations: a clinical assessment

Six patients undergoing major elective vascular operations received an average of 1,700 ml. of intraoperative autotransfusion of shed blood. The patients were anticoagulated systemically during operation. The mean platelet count (156,000 per cubic millimeter and fibrinogen value (257 mg. per 100 ml.) were normal in autotransfused blood and the mean hemoglobin level was slightly below normal (11.5 Gm. per 100 ml.). Plasma hemoglobin values were variable. No patient suffered any complication that could be attributed to autotransfusion. Donor blood transfusion was avoided in five of the six patients by salvage and reinfusion of shed blood. No evidence of coagulopathy was found in any patient as measured by platelet count, fibrinogen level, prothrombin time, partial thromboplastin time, euglobulin clot lysis, and fibrin degradation products. The technique of intraoperative autotransfusion is described in detail.